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pRIO CITY OF PRIOR LAKE Date Recd
0. �'e HEATING/AIR CONDITIONING/FIREPLACE PERM 3, z�,I)
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`�jN o��` 1.pins` File PERMIT NO /70
NES 2.Green City
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS4J/ V WIND L �.D sO ! , we___ (office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER ��, / � .Jr
'v
(Name) l.�/V Gi (Phone)
(Address)
i .fYVJ(C Coat t . aczw. i_Cuer (Phone) 7603 3/S 7Scx;)
401 79(7,r; l OctL Ave- S loo ) ciAcAmtpt tome.) 5-453110
(Address) (City) (Zip Code)
0. .I .y '-r .. r V r & (Phone) 7X03 57 (47 -7?-1
1- - I T SIGNAT is ✓G'5.9-- DATE / / ii
APPLICANT PLEASE COMPLETE BELOW
❑NEW CONSTRUCTION ❑REPLACEMENT ❑ALTERATIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
PLEASE NOTE: Air Conditioner
['Warm Air Plants 0 Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
❑Mechanical 0 Radiation Fireplaces with Box Additions or
❑Air Conditioning 0 Special Devices
OVent S stem 0 Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLAC , AKE AND MODEL A�—i 44(-- 510 0 OJ fefrii. S -
FEE SCHEDULE
Industrial,Commercial&Multi-Family 1%of job cost Residential,Gas Fireplace $49.50
$49.50 minimum
Residential,Heating&A/C(New Construction) $149.50 Residential,Additions&Alterations $49.50
Residential,Heating Only(New Construction) $64.50 Residential,AC Only $49.50
Estimated Cost$ Building Permit #
HEATING PERMIT FEE $ &-
STATE SURCHARGE $ S
TOTAL PERMIT FEE $ c1�Q 1J
(Office Use Only) ..c2(..
/
This Application Becomes Your Building Permit When Approved Paid - . 5-2) Rec 1 No. 62."571...0
Building Official Date Dates. 24, l/1/ By ,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372